An integrated approach to oral health in aged care facilities using oral health

practitioners and tele-dentistry in rural Queensland: A Quality Improvement Report.

Author Manuscript
*Anna Tynan1,2, Lisa Deeth3, Debra McKenzie4, Carolyn Bourke3, Shayne Stenhouse3,
Jacinta Pitt5, Helen Linneman4

1
Research Support Team, Darling Downs Hospital and Health Service, Baillie Henderson
Hospital, PO Box 405 Toowoomba, Queensland, 4350.
2
The Rural Clinical School, The University of Queensland, Herston Road, Herston,
Queensland, 4006.
3
Tele-Health Team, Darling Downs Hospital and Health Service, Baillie Henderson Hospital,
PO Box 405 Toowoomba, Queensland, 4350.
4
Toowoomba Oral Health Clinic, Toowoomba Hospital, Darling Downs Hospital and Health
Service, 280 Pechey Street, Toowoomba Queensland 4350
5
Mt Lofty Heights Nursing Home, Darling Downs Hospital and Health Service, Rifle Range
Rd, Toowoomba, QLD 4350.

*Corresponding Author
Anna Tynan
[email protected]
Baillie Henderson Hospital, PO Box 405 Toowoomba, Queensland, 4350
Phone: 46998056

Author Contribution
Research concept, design and fieldwork was completed by AT and LD. Design of work
program was completed by HL, DM, JP, CB, SS and LD. Assistance with fieldwork and
design of audit was completed by DM. Drafting of manuscript was completed by AT and
LD. Revision of manuscript for critical context was completed by HL, CD, SS, DM, JP and
LD. All authors have read and approved final version for publication.

This is the author manuscript accepted for publication and has undergone full peer review but
has not been through the copyediting, typesetting, pagination and proofreading process, which
may lead to differences between this version and the Version of Record. Please cite this article
as doi: 10.1111/ajr.12410

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Acknowledgements
This study was supported by a Pure Land College Research Scholarship through the
Toowoomba Hospital Foundation. The authors would also like to thank the staff and
residents of the participating residential aged care facilities.
Author Manuscript

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Article type : Quality Improvement Reports
Author Manuscript
An integrated approach to oral health in aged care facilities using oral health
practitioners and tele-dentistry in rural Queensland: A Quality Improvement
Report.

ABSTRACT
Problem
Residents of residential aged care facilities (RACF) are at very high risk of
developing complex oral diseases and dental problems. Key barriers exist to
delivering oral health services to RACFs particularly in regional and rural areas.

Design
A quality improvement study incorporating, pre and post chart audits; pre and post
consultation with key stakeholders including staff and residents; expert opinion on
cost estimates; and field notes was utilised.

Setting
One regional and three RACFs situated in a non-metropolitan Hospital and Health
Service in Queensland.

Key Measures for Improvement

Key measures included number of appointments required at an oral health facility
avoided; feedback on program experience by staff and residents; compliance with oral
health care plan implementation, and observations of costs involved to deliver new
service.

Strategies for Change

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The model developed incorporated a visiting Oral Health Therapist (OHT) for
screening, education, simple intervention and referral to a Dentist for a live-stream
Tele-Dentistry session if required.

Author Manuscript
Effects of Change
Results showed an improvement in implementation of oral health care plans and a
minimisation of need for residents to attend an oral health care facility. Potential
financial and social cost savings for residents and the facilities were also noted.

Lessons Learnt
Screening via the OHT and Tele-Dentistry appointment minimises the need for a visit
to an oral health facility and subsequent disruption to residents in RACFs.

Key words: Tele-dentistry, Aged Care, Oral Health, Tele-Health, Residential Aged
Care.
Word count: 1853 words

What is already known?

- Delivery of oral health services to residential aged care facilities are
challenging particularly in rural and regional settings.
- New technologies in Dentistry such as Tele-Dentistry, have become available
that allow consultations with Dentists to be conducted remotely via live feed
through an intraoral camera probe.
- Access to Oral Health Therapist in residential aged care facilities has been
shown to improve outcomes of residents, however not all conditions can be
addressed without advice from a Dentist.

What this paper adds?

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 - This paper details an integrated oral health program for RACFs that
incorporates an Oral Health Therapist and Tele-Dentistry which has not been
described before.
- This model is potentially transferrable to other RACFs in both public and
Author Manuscript
private settings.

CONTEXT
Institutionalised older adults in residential aged care facilities (RACF) are at very high
risk of developing complex oral disease (1, 2). All aged care residents should have
regular oral health assessment and screening by trained staff, with face to face patient
examinations regarded as the most accurate method for correct oral health diagnosis
(3, 4). However, evidence exists of high levels of oral disease and poor records of
accessing Dentists within this population (4-8). These issues are further exacerbated
in regional and rural settings where access to services may be already limited (9).

New technologies in Dentistry such as Tele-Dentistry have been developed that may
provide an alternative to delivering oral health services (10-13). Tele-Dentistry has
progressed beyond live videoconferencing with a range of electronic communication
technologies now available (10). In particular, live stream Tele-Dentistry has been
developed which allows an operator to provide “live-feed” video inside people’s
mouths to Dentists located offsite for further advice or review (14).

The Darling Downs Hospital and Health Service covers a large geographical area
(85,854 km²) incorporating regional and remote communities. The health service
includes 6 RACFs and 3 multipurpose health services that include residential aged
care facilities. This quality improvement report describes a collaboration between the
health services’ Telehealth Department, Oral Health Team and RACF staff that aimed
to enable residents in rural and regional RACFs to have better access to oral health
services.

PROBLEM
Previously, a Dentist from the health service’s oral health clinic would visit the
RACFs on an adhoc basis. Any interim identification of oral health issues and

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referral was the responsibility of RACF staff. Over time, the Dentist’s visits became
more sporadic resulting in attendance at an oral health facility becoming the only
option. Due to the physical and cognitive difficulties of many of the residents, the
Queensland Ambulance Service was frequently required for transportation. A
Author Manuscript
standard check-up could take up to 8 hours due to travel distance and waiting time,
appointment time, causing significant disruption to the resident’s daily routine.

The Telehealth Service, Oral Health Team and RACFs within the health service
formed a partnership to look at alternative ways to deliver a more effective oral health
service to residents. The model developed incorporated a visiting Oral Health
Therapist (OHT) for screening, simple intervention and referral to a Dentist for a live-
stream Tele-Dentistry session if required. The purpose of this quality improvement
study is to describe the development and implementation of this integrated model of
care at 1 regional and 3 rural RACFs and outline lessons learnt. A summary of
attributes of the facilities are listed in Table 1. Prior to conducting this project
approval was received from Darling Downs Hospital and Health Service Human
Research and Ethics Committee (HREC/15/QTDD/38).

INSERT TABLE 1

KEY MEASURES FOR IMPOVEMENT

Key measures included number of consultations at an oral health care facility avoided;
feedback on experience with program by staff and residents; implementation of oral
health care plans, and observations of costs involved to deliver new service.

PROCESS OF GATHERING INFORMATION

Chart audits were completed before and after introduction of the model and included
details about status of oral health care plans. Data were also collected on the number
of residents screened by an OHT, use of Tele-Dentistry technology and need for
referral to an oral health facility. Field notes were completed to record information
about decision making process and feedback from residents and staff. Cost estimates
of running the program were based on expert opinion of key stakeholders together
with operational data.

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ANALYSIS AND INTEPRETATION
Chart audits assisted with monitoring oral health care plan compliance. Data
collection on services received assisted with demonstrating type and location of oral
health service access. Costs estimates were collected to demonstrate potential
Author Manuscript
financial impact of new service. In order to understand satisfaction with new service
and potential areas for improvement, consultations were conducted with key
stakeholders.

STRATEGY FOR CHANGE

Trial of the new model commenced in November 2014. A visiting OHT was
employed to conduct initial oral health screenings, intervention, and provision of oral
health promotion activities to the RACFs. Access to a dedicated oral health
professional in RACFs has previously been shown to improve oral health care
outcomes of residents (15, 16). For the screenings, consenting residents received an
oral health review by the OHT in the privacy of their own room and a personalised
oral health care plan that was placed in the resident’s bathroom. Each RACF also
had a nurse allocated to the oral health portfolio. The primary purpose of this role was
to ensure compliance with the oral health accreditation and be trained specifically by
the OHT in order to disseminate knowledge to other RACF staff.

If an issue was discovered during screening by the OHT that required further
investigation, a referral was made for review by a Dentist via Tele-Dentistry. The
Tele-Dentistry appointment involved the OHT utilising an intraoral camera probe to
transmit a live feed of the resident’s mouth to a Dentist who was located on another
campus. The intraoral camera was connected directly to a PC, laptop or telehealth
equipment and was operated via ‘point and shoot’ by the OHT. Live images were
transmitted through videoconference software, and still images were also captured
and stored for later review. During the Tele-Dentistry appointment the Dentist
advised a treatment plan for the OHT to commence, or confirmed that the resident
was required to be seen in person at an oral health facility.

EFFECTS OF CHANGE
Need for Attendance at Oral Health Care facility

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A total of 116 residents were screened by an OHT over a 6 month time frame at the 4
RACFs. Where possible the OHT provided intervention and prevention advice such
as education to the resident or nurse. Of the 116 screened, 33 residents (28%)
required a Tele-Dentistry review and a further 19 residents (16%) required an in
Author Manuscript
person appointment at an oral health facility (See Table 2). Access to Tele-dentistry
after screening prevented 14 residents (12%) from the need to travel to an oral health
facility saving them from unnecessary disruption. No adverse events, patient
complaints or incidents were reported during the trial.

INSERT TABLE 2

Oral health care management within RACF

Initial chart audits demonstrated inconsistencies with application of oral health care
plans across the facilities. Prior to commencing, chart audits revealed that 53% of
residents at participating RACFs had an oral health care plan that met the needs of the
residential oral health assessment. Following the trial, there was an observed increase
to 96% of residents with an appropriate oral health care plan.

Associated Costs of new model

Estimated unit costs of the integrated oral health model for RACFs including training,
equipment, transport, and staff time are presented in Table 3. Screening by OHT at
the RACFs was shown to be the least cost scenario. Set up of Tele-Dentistry
appointment and Dentist time increased costs in Scenario 2 and 3. Transportation
costs for each scenario was a significant proportion of total costs particularly due to
the large distances between facilities in this rural setting. However, it is likely that the
OHT would complete a number of screening or Tele-Dentistry appointments at each
RACF visit minimising transport costs. Attendance at an oral health facility by a
resident incurred the highest costs.

INSERT Table 3

Perceived impacts on staff and residents

Positive feedback was received from staff, residents and families of the RACFs
following the trial. Staff members and managers reported increased awareness of

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residents’ oral health needs and prevention requirements; improved access to
resources for oral health management; and observed savings in minimising need to
transport resident to an oral health facility. In particular, staff and family reported
treatment at the RACF minimised disruption to high care residents particularly those
Author Manuscript
with dementia. Facility managers also reported a positive cultural change of staff
towards oral health care that they attributed to education and access to oral health
specialists onsite more regularly. The initial screenings by the OHT were also
observed to result in potential problems being identified and addressed earlier than
previously experienced.

LESSONS LEARNED AND NEXT STEPS

Treatment and screening by an OHT and access to Tele-dentistry assisted in
improving oral health management. The process also allowed for residents to be
reviewed and treated in the comfort of a familiar environment, limiting the need for
residents to attend an oral health facility. Working with the OHT was also noted as
beneficial to improving inter-professional education of RACF staff which has
previously been described as important in improving oral health of residents (17, 18).
There were also potential financial and social cost savings for residents and the
facilities.

A number of lessons were observed during the trial. Initially obtaining consent from
families for oral health review by the OHT for eligible residents was difficult. To
overcome this, consent was included in the residents admission pack. Management
of residents with dementia by the OHT also required some key considerations. The
OHT received education on how to best support people with dementia participating in
their oral health reviews. The regularity of the OHT visit also allowed for residents to
become more familiar and comfortable with the process.

Following the trial, the program is being rolled out to other RACFs within the health
service. A more formal research project is currently underway to investigate the
impact and experience of the integrated model for residents and RACF staff across the
facilities.
REFERENCES

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13. Khan SA. Teledentistry in practice: literature review. Telemedicine journal
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 Table 1: Summary of Residential Aged Care Facilities (RACFs)
Facility Number of Beds Access to Dentist
RACF 1 40 bed facility 4.6kms to nearest public
Author Manuscript
RACF 2 70 bed facility
dentist
31kms to nearest public
dentist
RACF 3 14 bed facility 210kms to nearest public
dentist
RACF 4 5 bed facility 82kms to nearest public
dentist or 44kms to closest
private dentist

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Table 2: Oral Health Services Provided per Residential Aged Care Facility
Facility No. of Residents No. of Residents No. of Residents No. Oral Health
Screened* requiring review by requiring appointment Facility appointments
Tele-Dentistry at Oral Health Facility avoided

RACF 1 34 6 3 31
40 beds Author Manuscript
RACF 2 64 18 11 53
70 beds

RACF 3 13 4 3 10
14 beds

RACF 4 5 5 2 3
5 beds

TOTAL 116 33 (28%) 19 (16%) 97 (84%)

*Number screened depended on number of beds filled within RACF and consent of residents and their families.

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Table 3: Costs associated with Oral Health Services Provided
Ongoing Costs
Scenario 1: Oral Health Therapist (OHT) Screening at RACF: Per Appointment
Average (AUD) Minimum (AUD) Maximum (AUD)
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Return trip to RACF: Transport costs

Cost of OHT for return trip

$108.10

$59.55 (1.5hr)
$ 6.10

$13.20
$277.20

$158.80

Cost of OHT per appointment onsite $19.80 (30mins) $9.90 $ 39.70

Cost of Nurse for total time required $14.10 (30mins) $ 4.70 $ 28.10
during OHT screening

TOTAL COSTS $201.55 $33.90 $503.80

Scenario 2: Tele-dentistry at RACF: Per Appointment
Average (AUD) Minimum (AUD) Maximum (AUD)
Return trip to RACF: Transport Costs $108.10 $ 6.10 $277.20
Cost of OHT for return trip $59.55 (1.5hr) $13.20 $158.80

Cost of OHT per appointment onsite $29.75 (45mins) $19.80 $ 59.50

Dentist time $30.10 (30 mins) $15.05 $ 60.20
Cost of Nurse for total time required $14.10 (30mins) $ 4.70 $ 28.10
during Tele-Dentistry Appointment
TOTAL COSTS $241.60 $58.85 $583.80
Scenario 3: Attendance at Oral health Clinic by Resident: Per Appointment
Average (AUD) Minimum (AUD) Maximum (AUD)
Transport of resident via facility car $108.10 $ 6.10 $277.20
OR
Transport via Ambulance $261.30 (return) *
Staff escort time to accompany resident $112.40 (4 hrs) $28.10 $225.10
(AIN)
Dentist time $30.10 (30 mins) $15.00 $ 60.10
TOTAL COSTS Via car $250.60 $49.20 $562.40
Via Ambulance $403.80 $304.40 $546.50

Set up Costs Tele-Dentistry**

 Costs of Tele-dental equipment: $14,938.00
Flexiscope Microvision Camera Module with Docking Station and Intra Oral Probe *based on cost July 2014

 Disposable equipment costs $215.70

 Training $60.00
 Other initial set up costs including trolley $503.43
TOTAL $15,717
Assumptions

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- Each appointment was conducted on individual days
- RN and OHT was present during both OHT screening and Tele-dental appointment.
- The Australian Tax Office 2015 travel reimbursement schedule for a 2.2 litre engine was used to quantify travel cost at 66c/km.
- Average distance between closest public oral health facility and RACF was considered over 4 sites with average return trip
being 163.80km, minimum distance 9.2 km and maximum distance 420km.
- Salaries of the oral health personnel involved was based on the Queensland Health, Health Practitioner Award for the Oral
Author Manuscript
Health Therapist and Queensland Health at level HP3.4 and Level L2.1 for Dental Stream for the Dentists as at 2015.
- Nursing salaries were based on Queensland Health Nursing wage rates as at 2015 for Nurse Grade 1.6.
- Costs not taken into consideration include the cost of internet or cost of the room to host the appointment
-* One price only for Queensland Ambulance Service
-**Set up costs included the one off cost of purchasing a trolley and the Tele-Dentistry equipment, and disposable equipment was
estimated to last on average up to 50 residents.

RACF: Residential Aged care facility AIN: Assistant in Nursing RN: Registered Nurse
OHT: Oral Health Therapist EN: Enrolled Nurse

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